The effect of infliximab on skin lesions in a patient with scleroderma (CREST)

Background

Skin lesions refractory to treatment are a source of morbidity in patients with scleroderma (CREST) and may result in amputation. No established DMARD is available for this disorder.

Objective

The aim was to report the effect of infliximab in combination with methotrexate (MTX) on refractory skin lesions in a 46-year-old woman with scleroderma (CREST).

Case report

In 1991, the patient was diagnosed with scleroderma (CREST). Despite several treatments (initially D-penicillamine and colchicine, subsequently MTX, colchicine and misoprostol), she developed severe digital ulcerations, resulting in multiple amputations with difficult wound healing afterward. Since 1999, she was treated with MTX, colchicine and alprostadil. In August 2002 she developed necrosis at the fingertip of digit IV right. Despite hyperbaric oxygen treatment and pulse therapy with corticosteroids, the necrosis worsened. Therefore, infliximab (3 mg/kg iv at weeks 0, 2 and 6, and every 8 weeks thereafter) combined with MTX (10 mg/w im) was started. The patient also had ulcerations at digit II left and at the knees, and suffered from severe Raynaud's attacks. After the second infusion, the ulcerations started to heal. Although an amputation of distal phalanx of digit IV could not be avoided, infliximab was continued. The amputation wound healed quickly, the ulcerations became considerably smaller, and she developed no new skin lesions. The inflammatory parameters remained stable and her general condition improved; she gained weight (6 kg), had less pain in the fingers and fewer Raynaud's attacks, and her skin became more supple. Infliximab was stopped after eight infusions. Now, 4 months later, the previous ulcerations remain healed, no new digital lesions occurred and the inflammatory parameters are stable.

Conclusion

We present a patient with scleroderma (CREST) and refractory skin lesions. Infliximab combined with MTX was well tolerated and effective in the healing of ulcerative lesions.